IRHA Fall Conference September 10, 2015 Des Moines, IA Keith J. Mueller, PhD Director, RUPRI Center for Rural Health Policy Analysis Head, Department of Health Management & Policy University of Iowa College of Public Health
Transformation in Health Care Delivery: The Future in Rural America Delivered to the 2006 Nebraska Rural Health Conference 2
12 year-old Tommy develops cold symptoms and Mom takes him to Wal-Mart for care because the store is now a Super Wal-Mart offering health care services that include: Routine care Children and adolescent Health Diagnostic testing X-Ray imaging Vaccinations Preventative care [taken from www.quickqualitycare.com/services.htm on August 11, 2006; current sites in Tampa, Sturt, Fort Myers FL] Mom pays the bill on site, $30 in 2006 dollars, and withdraws the money from the family health savings account 3
85-year-old Elizabeth has recently experienced worsening of the arthritis condition that had been only a minor pain in the. She had been taking over-the-counter pain killers purchased at the local convenience store. Now she has multiple choices for upgrading care: Establish a medical home in Chadron, a mere 22 miles away Also purchase her medications in Chadron at Wal-Mart or Safeway Use mail order to purchase 90 day supplies of some medications As she needs help in activities of daily living hope neighbors can help because the home health agency does not serve Crawford (too costly) Give up her lifelong commitment to remain in Crawford and move to a place with full services in the community 4
An integrated health care delivery system offers local access to: Same day surgery performed by rotating surgical teams with telehealth back-up 24/7 primary care in the local clinic (not the hospital ER) Local pharmacy which also supports the hospital and skilled nursing facility Behavioral health services through a social worker backed up with telehealth General surgery, delivery services, diagnostic imaging on site at the CAH Assisted living and independent living supported by a regional nursing service And linked to other health care services through a fully automated information system that includes electronic health records and ability to crosswalk to personal health records 5
Expenditures for health care are spiraling beyond any single fix Complexity of health care problems present more opportunities for medical error Millions with limited access because of cost, availability, cultural misfit Health care professionals with declining morale Breakthrough policies that contribute to problems: Medicare Part D WILL IT ALL IMPLODE? 6
Fast forward to 2014, 2015 Delivery system: Health care leads all sectors in mergers and acquisitions, challenging anti-trust experts to balance enhanced service/lower cost with potential for higher prices Delivery system: Hospital closure re-emerging as a rural rallying cry 7
Payment system: Commercial insurance and consumer-driven design, pay for value, use of shared risk models Payment system: Medicare and use of Medicare Advantage, Accountable Care Organizations, Value- Based Purchasing Payment system: Medicaid use of managed care, accountable care organizations 8
Tipping point reached: Why changes at the margin yield organizational responses Leadership commitment within healthcare sector Demands from the consumer Economic driver the largest sector of economic growth 9
10
Affordable: to patients, payers, community Accessible: local access to essential services, connected to all services across the continuum High quality: do what we do at top of ability to perform, and measure Community based: focus on needs of the community, which vary based on community characteristics Patient-centered: meeting needs, and engaging consumers in their care 11
Community-appropriate health system development and workforce design Governance and integration approaches Flexibility in facility or program designation to care for patients in new ways Financing models that promote investment in delivery system reform 12
Local determination based on local need, priorities Create use of workforce to meet local needs within the parameters of local resources Use grant programs 13
Bring programs together that address community needs through patient-centered health care and other services Create mechanism for collective decision making using resources from multiple sources 14
How to sustain emergency care services Primary care through medical home, team-based care models Evolution to global budgeting 15
Shared savings arrangements Bundled payment Evolution to global budgeting New uses of investment capital 16
Regional megaboards Aggregate and merge programs and funding streams Inter-connectedness of programs that address personal and community health: the culture of health framework Strategic planning with implementation of specifics Develop and sustain appropriate delivery modalities 17
A convener to bring organizations and community leaders together: who and how? Critical to success: realizing shared, common vision and mission, instilling culture of collaboration, respected leaders Needs an infrastructure Reaching beyond health care organizations to new partners to achieve community goals 18
From a paper recently posted by the RUPRI Health Panel, Care Coordination in Rural Communities: Supporting the High Performance Rural Health System June, 2015. http://www.rupri.org/wp-content/uploads/2014/09/care-coordination-in- Rural-Communities-Supporting-the-High-Performance-Rural-Health- System.-RUPRl-Health-Panel.-June-2015.pdf 19
Conceptually, care coordination is a deliberate, person-centered, assessment-based and interdisciplinary approach that links health care and social support services within clinical settings, between clinical settings, and between clinical and community settings Requires moving beyond a medical framework toward a model that supports health services and social support systems, integrating clinical and nonclinical providers 20
Community / Regional Delivery Referral Systems Care coordination is delivered by community or regional entities in support of primary care practices. Examples include Medicaid care coordination initiatives in Colorado, Montana, New Mexico, North Carolina, and Alabama. Population Health Care coordination is part of a broader strategy for community health improvement provided through collaborative coalitions of community stakeholders and/or public-private partnerships. Examples include Vermont Blueprint for Health, Buncombe County, NC*, and Taos Pueblo, NM*. Primary Care / Health System Delivery Disease/Chronic Condition Management Care coordination targets high-risk individuals and is delivered within a primary care practice setting, health care system, or ACO. Examples include Geisinger ProvenHealth Navigator, Safety Net Medical Home Initiative demonstration participants. Preventive Services and Wellness Care Care coordination originates from a primary care or health care system framework that extends into the community for the benefit of a local population. Examples include Community Health workers in Alaska, Sustainable Williamson*. Patient Support Systems Focus Community Health Focus 21
Effective Information Exchange (HIE) o Timely and appropriate sharing of relevant information o Accessible and interoperable among all care participants o Relies on strong relationships across care continua providers Trained, Available Workforce o Train people in appropriate care coordination roles, and roles clearly defined and understood among all care participants o Functions as the link between disparate elements of personcentered care plans o Facilitates appropriate delivery of health and social services o Engages patients in fulfilling their part of overall health plans 22
Evaluation and Improvement of Care Coordination Programs o Knowledge of key activities impacting achievement of patient-centered plans and experience o Ability to track and monitor patient-specific and communitywide measures o Awareness of challenges and issues in care coordination, and having a process to address them o Identify and prioritize key improvement areas over time 23
1. Affordability 2. Accessibility 3. Community focus 4. High quality 5. Patient-centeredness 24
Facilitates patient-centered care integration across settings and disciplines o Clinical and non-clinical; medicine and human/social supports Utilizes scarce rural resources in a way that responds to the distinct needs of each community 25
Improves clinical care quality through timely information sharing among care participants o Clinicians, patients, their families and caregivers, and community-based support providers Focuses on community because it builds on local resources and assets, and supports personcenteredness pillar, using systems of support that help people engage in and drive their own health processes 26
Funding grants, demonstration programs Financing payment policies o Per member per month (PMPM) o Multi-payer payment for shared capacity o Population-based payments Global budgets, capitation, bundled payment o Medicare CPT codes Transitional Care Management, Chronic Care Management 27
Recommendation 1: Care coordination program effectiveness should be assessed using metrics related to the five pillars of a high performance rural health care system: 1) Patient engagement as it relates to the pillar of patient-centeredness ; 2) The development and use of local community-based resources, including formal and informal linkages with social service providers, as a reflection of community focus ; 3) Reducing total cost of care, as absorbed by patients, payers, and/or taxpayers in support of affordability ; 4) Improved access to services facilitating health maintenance and wellness reflecting the pillar of accessibility ; 5) Improved overall quality of care that promotes the pillar of high quality. This recommendation should be implemented through requirements for receiving grants, payments, and other support to develop care coordination programs. 28
We also encourage development and implementation of rural care coordination programs using current policy levers: Recommendation 2: New Medicare payment for chronic care management services provides incentives to include care coordination services in primary care practices. The Panel recommends flexibility regarding access to care management services requirements, especially in remote, frontier regions. We also recommended, and continue to recommend, that the Centers for Medicare and Medicaid Services (CMS) develop a methodology that would make this new payment available to Rural Health Clinics and FQHCs. Recommendation 3: The new CMS supported Health Care Payment Learning and Action Network should, as one of its foci, provide a platform to learn more about refining payment systems to reward care coordination programs that contribute to all five pillars of the rural high performance system. 29
We recommend developing, implementing, and evaluating care coordination programs using existing grant, loan, and demonstration programs: Recommendation 4: Grant programs focused on rural health should be designed to serve as catalysts for community-based health systems and organizations to collaborate in new care coordination programs, specifically incorporating requirements to measure achievements across all five pillars. Recommendation 5: Support for new technology, including telehealth and new information systems, should facilitate care coordination through capabilities to extend services into homes and share information across providers and organizations. Funding 16 available through public grants and private foundations could be used as investment capital. Recommendation 6: Training the new workforce needed in care coordination (e.g., care coordinators, health coaches, and patient navigators) should be incorporated into special grant programs such as the SIM implementation grants. Similarly, public grant funds or private sources should be used to create recruitment incentives, such as loan forgiveness, to attract the workforce needed into rural communities. 30
Finally, consideration should be given to new policy directions: Recommendation 7: As payment systems evolve toward population-based payment, special consideration should be given (as a transition strategy) to financing the infrastructure needed for care coordination program development. Population-based payment systems would then sustain care coordination services. Recommendation 8: Support should be provided for research to determine the relative effectiveness of different care coordination approaches in rural settings. Research results should be widely available, and a platform should be created to exchange best practices. 31
Care coordination should be built on two pillars of a high performance rural health system patientcenteredness and community focus. Successful programs will also contribute to the other three pillars of the high performance system affordability, access, and quality. 32
Draw from March 2015 RUPRI paper, Accountable Care Communities in Rural: Laying the Groundwork in Humboldt county, California. http://www.rupri.org/wp- content/uploads/2014/09/accountable-care-communities-in- Rural-Laying-the-Groundwork-in-Humboldt-County-3.pdf 33
Collaboration and partnership for effective local governance Structure and process to support the ACC Leadership and support from strong champions Defined geography and geographic reach Targeted programmatic efforts 34
Membership fees or contributions from member organizations Community benefit funds from tax-exempt hospitals contributed or loaned to ACC projects Regional global payment or portion of shared savings Linkages between health care and public health or community partners Health and wellness trusts Social investing from venture capital Community development financing 35
Rural Health Value http://ruralhealthvalue.org he RUPRI Center for Rural Health Policy Analysis http://cph.uiowa.edu/rupri The RUPRI Health Panel http://www.rupri.org 36
Department of Health Management and Policy College of Public Health, N232A 145 Riverside Drive Iowa City, IA 52242-2007 319-384-3832 keith-mueller@uiowa.edu 37